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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 33
| Issue : 2 | Page : 51-56 |
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Acute abdomen in patients above 60 years
Ihsan Ali Mohammed, Harith Fakhri Shakir, Hayder Sabah Al-Kawaz
Iraqi Ministry of Health, Al-Yarmouk Teaching Hospital, Baghdad, Iraq
| Date of Submission | 21-Apr-2020 |
| Date of Decision | 21-May-2020 |
| Date of Acceptance | 20-Jun-2020 |
| Date of Web Publication | 6-Jul-2023 |
Correspondence Address:
Dr. Ihsan Ali Mohammed
Emergency Department, Al-Yarmouk Teaching Hospital, Baghdad
Iraq
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IRJCM.IRJCM_1_21
Background: Acute abdomen is the medical term used for pain in the abdomen that usually comes on suddenly and is so severe that a person may seek emergency treatment; it can signal a variety of more serious conditions, some of which require immediate medical care and or surgery. Aim of the Study: The aim of this study was to evaluate the causes of nontraumatic acute abdomen and their presentation in elderly patients within the Emergency Department at Al-Yarmouk Teaching Hospital and their correlation to the final diagnosis and outcome. Patients and Methods: A descriptive study was conducted on 121 elderly patients aged 60 years and above, complaining of acute abdominal pain (traumatic cases were excluded and unknown patients fate), presented to the emergency unit of Al-Yarmouk Teaching Hospital. The study was done for a period of 13 months (February 1, 2015, till April 1, 2016). The data were collected by interviewing questionnaire, reviewing of records, taking some measurements, and physical examinations. Data were analyzed using the SPSS program version 22. Results: Patients with acute abdomen were included in the present study with a mean age of 68.4 ± 7.5 years with a female-to-male ratio of 2.1:1. The most common chief complaint was pain presented in 100 (59%) of patients, 50 patients (41%) presented with a duration of chief complaint in ≤24 h, 56.2% of the studied patients were hyperthermia, 65% were hypertensive, mean pulse rate of studied patients was 110 ± 12 beat/min, 75.3% of them had tachycardia, mean respiratory rate of studied patients was 19 ± 2/min, and 52% of them had tachypnea. The most common site of pain was right iliac fossa (24.8%), Murphy's sign was positive among 19 patients (16%), tenderness was present in 114 of the patients (94%), abdominal guarding was positive in 106 of the studied patients (88%), jaundice was observed in 27 (22%) patients, dehydration was present among 79 (65%) of studied patients, and 76 of the patients (62.8%) had elevated white blood cell. Cardiovascular diseases were the most common associated diseases (47%). Ultrasound findings of studied acute abdomen patients presented to the emergency department revealed that 26 of them (21.5%) had gallbladder abnormality, 24 (19.8%) had no specific ultrasound findings, and the X-ray finding was abnormal among 44 (36.4%). The most common diagnosis was perforated viscus for 18 (14.8%) patients. More than two-thirds (72; 59.5%) were treated surgically with mortality rate was 18 (14.8%). Conclusion: Pain was the most common complaint among the elderly with acute abdomen, and the right iliac fossa was the common site of pain. Most patients attended the hospital late (after 24 h from starting the symptoms). Perforated viscus and cholecystitis appear to be the main causes of acute abdomen among Iraqi elderly people.
Keywords: Acute abdomen, elderly, emergency department
How to cite this article:
Mohammed IA, Shakir HF, Al-Kawaz HS. Acute abdomen in patients above 60 years. IRAQI J COMMUNITY MED 2020;33:51-6 |
| Introduction | |  |
Acute abdomen is the medical term used for pain in the abdomen that usually comes on suddenly and is so severe that a person may seek emergency treatment; it can signal a variety of more serious conditions, some of which require immediate medical care and/or surgery.[1]
In the USA, abdominal pain is a chief complaint in 3%–13% of elderly patients coming to the emergency department, these patients are 6–8 times more likely to die and twice as likely to need surgery as their younger counterparts, misdiagnosis is common, ranging from 18% to 60%.[2] In Turkish, the most common surgical indication among the elderly was acute cholecystitis (26.09%), followed by intestinal obstruction (25%). Morbidity was established at 22.8% and mortality as 15.2% with the most common cause of mortality was mesenteric vascular occlusion.[3]
In Iraq/Bagdad Teaching Hospital, the most common cause of acute abdomen among patients above 60 was intestinal obstruction (57%), acute cholecystitis (20%), and perforated peptic ulcers (8%). Mortality was not related to age but related to the cause of acute abdomen, number of medical diseases, and time delay in performing surgery.[4]
The mechanisms of acute abdomen in the elderly patient are not different from the ones of young adults, what differs is the large number of associated diseases and specific geriatric pathology, ischemic disorders, and diverticular disease.[5],[6],[7],[8],[9]
The general causes of the acute abdomen may be divided into five large categories: The inflammatory causes may be divided into two subgroups: bacterial and chemical, some common examples of the bacterial causes would include acute appendicitis, diverticulitis, and some cases of pelvic inflammatory disease, an example of a chemical cause would be a perforation of a peptic ulcer, where spillage of acid gastric contents causes an intense peritoneal reaction, mechanical causes of an acute abdomen include such obstructive conditions as incarcerated hernia, postoperative adhesions, intussusceptions, malrotation of the gut with volvulus, vascular causes of AA include mesenteric arterial thrombosis or embolism, when the blood supply is cutoff necrosis of tissue results with gangrene of the bowel, neoplastic causes such as ovarian tumor, and congenital defects can produce AA (these are not included in our study).[7],[10],[11],[12],[13]
Imaging plays a larger role in the workup of elderly patients with abdominal pain; it can be useful in detecting bowel obstruction, a dynamic ileus, nephrolithiasis, and perforation. Occasionally, gallstones may be observed, as well as late findings of mesenteric ischemia (i.e., pneumatosis intestinally). Chest X-ray (CXR) is helpful in excluding pneumonia, which is a cause of abdominal pain; it may demonstrate free intraperitoneal air under the diaphragm in patients with ruptured viscus.[14] Abdominal ultrasonography is the initial study of choice when evaluating biliary tract disease.[15] Computed tomography scanning plays an increasingly important role in the evaluation of elderly patients with abdominal pain, especially when the diagnosis is unclear; this imaging modality allows the identification of the site of gastrointestinal perforations and of ischemia and the determination of the most predictive signs in this diagnosis.[16],[17]
The current study was conducted aiming to evaluate the causes of acute abdomen and their presentation in nontraumatic elderly patients within the Emergency Department at Al-Yarmouk Teaching Hospital and the final diagnosis and outcome.
| Patients and Methods | | |
This is a descriptive study on 121 elderly patients aged 60 years and above, complaining of acute abdominal pain (traumatic cases were excluded and unknown patients fate), admitted to the emergency unit of Al-Yarmouk Teaching Hospital. The study was done for 13 months which extended from February 1, 2015, to April 1, 2016.
The data were collected through interviewing questionnaire, reviewing of records, taking some measurements, and physical examination. The questionnaire form was prepared through the modification of multiple questionnaires of national and regional studies on the acute abdomen and it covered demographic characteristics, chief complaints of patients, duration of the complaints, and associated medical illness. Privacy and confidentiality were considered after verbal consent. Elderly Patients were given the right to withdraw from the study at any time.
The examination of all patients was performed including vital signs (pulse rate normally 60–100 b/m, temperature normally 36.5–37.2 c., blood pressure normally systolic 100–135 and diastolic 60–85mmHg, and respiratory rate normally at rest 12–16 breath/m), general and abdominal examination plus investigation including white blood cell (WBC) count (normal value: 4000–11,000), radiography (CXR in erect position, full further abdominal X-ray, and KUB), and ultrasonography, then record the final diagnosis according to physician-based report. Data were analyzed using the SPSS program version 22 international software for statistical analysis, USA.
| Results | | |
A total of 121 elderly patients with acute abdomen were included in the present study with a mean age of 68.4 ± 7.5 years, 70 (57.8%) patients were in the age group of 60–69 years. Elderly males were 39 (32%) and females were 82 (68%); female-to-male ratio was 2.1:1 [Table 1]. | Table 1: The age of patients with acute abdomen distribution according to their gender
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The most common chief complaint was pain presented in 100 (59%) of patients, and the other complaints after pain were vomiting (31%) and fever (10%). In detail, 58 (49.7%) of acute abdomen patients presented with pain alone, 28 (23.4%) patients presented with pain and vomiting, 18 (14.8%) patients presented with vomiting alone, and 9 (7.4%) patients presented with pain and fever, etc., [Table 2].
The mean duration of chief complaint for acute abdomen patients was 43 ± 31 h, 50 (41%) patients presented with a duration of chief complaint in ≤24 h, and 71 (59%) patients presented in duration >24 h. Regarding vital signs, body temperature, blood pressure, pulse rate, and respiratory rate of studied patients, it is shown in [Table 3].
[Table 4] shows the location of abdominal pain at examination of acute abdomen patients was right iliac in 30 (24.8%) patients, generalized in 25 (20.7%) patients, left iliac in 12 (9.9%) patients, periumbilical in 12 (9.9%) patients, right hypochondrial in 11 (9.1%) patients, left hypochiondrial in 9 (7.4%) patients, epigastric in 8 (6.6%) patients, right lumbar in 6 (5%) patients, left lumbar in 4 (3.3%) patients, and suprapubic in 4 (3.3%) patients.
[Figure 1] shows the physical examination findings of acute abdomen in the elderly. Murphy's sign was positive among 19 (16%) of the patients with right hypochondrial pain. The tenderness was present in 114 (94%) of the patients. Abdominal guarding was positive in 106 (88%) of the studied patients. Jaundice was observed in 27 (22%) patients. Dehydration was present among 79 (65%) of the studied patients.
Concerning the WBC, 76 (62.8%) acute abdomen patients had elevated WBC count and 45 (37.2%) of them had normal WBC count with a mean count for was 9 ± 3.8 × 103/mm3. [Table 5] illustrates the associated diseases in patients with acute abdomen. | Table 5: The comorbidity with other conditions in elderly with acute abdomen
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Ultrasound and X-ray findings of studied acute abdomen patients presented to the emergency department revealed that 26 (21.5%) of them had gallbladder abnormality (wall thickening and or gall stone), 24 (19.8%) of them had no specific ultrasound findings, 22 (18.2%) free fluid, 12 (9.9%) had appendicular mass, 12 (9.9%) had abdominal solid mass, 7 (5.8%) enlarged ovaries, 7 (5.8%) sign of appendicitis, 7 (5.8%) aortic calcifications, and 4 (3.3%) pancreatic enlargement. X-ray finding (CXR, KUB, plain abdominal X-ray erect, and supine) in presented patients was abnormal among 44 (36.4%), as shown in [Table 6].
The diagnosis of acute abdomen patients presented to emergency department was perforated viscus for 18 (14.8%) patients, cholecystitis for 16 (13.5%) patients, bowel obstruction for 15 (12.7%) patients, MI for 8 (8.5%) patients, hernia for 12 (9.9%) patients, heart failure for 8 (6.6%) patients, appendicitis for 6 (4.9%) patients, aortic aneurysm for 6 (4.9%) patients, ovarian tumor for 6 (4.6%) patients, endometrial tumor for 5 (4%) patients, vascular occlusion for 5 (4%) patients, etc., as shown in [Table 7].
More than half, 72 (59.5%) of studied patients were treated surgically (explorative laparotomy, cholecystectomy, appendectomy, etc.,), 21.5% of them were treated medically, and 19% of them were treated conservatively. The final outcome of the studied patients was discharged healthy for 65 (53.7%) of patients (after surgical and medical intervention), 38 (31.5%) of them were discharged unhealthy for further management, and 18 (14.8%) of them died (10 patients died before admission, 2 patients died intraoperatively, and 6 patients died 1 week postoperatively), as shown in [Figure 2].
| Discussion | | |
Since the mean age of the population is increasing, acute abdominal pain in the elderly is becoming more significant and important for the physician, the definition of “elderly” varies among different studies but most authors define patients older than 60 years as elderly.[9]
In this study, elderly males were lower than females; the ratio was 1:2.1, similar results were reported in another study in Turkish.[18] However, unlike the result of research done in Al-Najaf Hospital, the males were higher.[19]
From the result of our research, the most common chief complaints of the studied patients were pain (59%), vomiting (31%), and fever (10%), this rate was less than a study in Ethiopia: abdominal pain, followed by vomiting which accounts 88.8% and 8.4%, respectively, were the most common presenting complaint,[20] but higher than the study done in Korea, the most frequent chief complaints were abdominal pain in (16.81%), dyspnea (13.96%), and fever (11.16%).[21]
Some patients in this study presented only with one complaint: 47.9% of patients complained of only pain, 14.8% only vomiting, and 0.8% complained of fever, while the others complained of more than one complaint.
Only 41% of our patients attended to hospital during the first 24 h from starting the symptoms. This result was higher than 23.8% which was reported by Al-Saiegh in Al-Najaf study,[19] but lower than another study in Greece, 83% of the patients presented within 24 h after the onset of their symptoms.[22]
The symptoms and signs in older patients are frequently milder and less specific than in younger adults with the same conditions, so the emergency physician must have a high index of suspicion based on clinical impressions rather than on “hard” data.[23]
During vital signs, measurements of the studied patients (56.2%) were increased body temperature, this result higher than measurements in study in Ethiopia (11%) feverish,[20] also higher than study in Greece (14%).[22] In our study, 65% were hypertensive and only 29% normotensive. These results disagree with measurements in research done in Ethiopia: (96.1%) normotensive.[20] About 75.3% of patients had tachycardia, this rate higher than in another study (61.4%) tachycardia.[22] While 52% of patients had tachypnea, 38% had normal respiratory rate, and 10% lower than normal rate.
During abdominal examination, 24.8% of patients had RIF pain, while in Greece, the patients located their pain mainly in the epigastrium (25%) and hypogastrium (35%).[22]
The majority of our patients (94%) had positive tenderness, and most of them 102 (84%) had negative Murphy's sign with reported sensitivity of 97% and predictive positive value of 93%.[24] Abdominal guarding was positive in 88% of the studied patients. Jaundice was observed in (22%) patients, and dehydration was present among (65%) of studied patients, this may be related to the late coming of patients to the hospital.
Knowing that elder patients with abdominal pain may have a serious cause with a paucity of findings, laboratory testing and imaging are often the mainstay of evaluating these patients, so routine complete blood cell counts are mandatory, both leukocytosis and leukopenia indicate infection or inflammation in the elderly patients.[1]
From the result of this research, 62.8% of patients had elevated WBC and the others had normal WBC. In comparison with research done in Greece (33%) had elevated WBC and (67%) were normal.[22]
In the present study, all the patients had a history of chronic medical illness. The most common associated diseases were cardiovascular (47%), 23% had pulmonary diseases, 18% had renal diseases, and 10% had malignancy. This agrees with previous researches also cardiovascular diseases were the most common (42.2%).[25] Other researches done in Baghdad General Hospital revealed that 35% had cardiovascular diseases, 16% had diabetes, and 10% had chronic obstructive pulmonary disease,[4] also agree with research done in Italy 47% of the patients had cardiovascular disease, 33% had chronic pulmonary disease, and 28% had neurological pathologies.[26]
The most common ultrasound findings of studied acute abdomen patients presented to the emergency department revealed that 21.5% of them had gallbladder abnormality, 19.8% of them had no specific ultrasound findings 18.2% had free fluid, 9.9% had mass in right iliac fossa, and 9.9% had pelvic mass. Plain films are used primarily to look for free air in cases of suspected viscus perforation or for bowel obstruction, in addition to CXR to exclude extra-abdominal pathology.[9],[15]
The result of this research revealed that 63.6% of the patients had no abnormal findings in X-ray. The result was higher (88%) reported in another study, while abnormal X-ray in our research was in 36.4% of patients versus 4.7%.[27]
In the present study, the most common clinical diagnosis was perforated viscus (14.8%), cholecystitis (13.4%), while bowel obstruction was the third cause (12.7%). In reverse to the research done in Basrah General Hospital revealed that the most common cause of acute abdomen was intestinal obstruction which occurred in (55%) of the patients, hollow viscus perforation (17%), acute cholecystitis (12%), mesenteric vascular occlusion (9%), and acute appendicitis (7%),[25] and in Bagdad General Hospital also, intestinal obstruction was the most common cause (57%), acute cholecystitis (20%), perforated peptic ulcer (8%), acute appendicitis (6%),[4] also the result was different in research done in Turkey: the first cause was acute cholecystitis (31.5%), strangulated hernia (18.2%), hollow viscus perforation (17.1%), bowel obstruction (10.5%), acute mesenteric ischemia (9.4%), acute appendicitis (8.3%), and upper gastrointestinal hemorrhage (5%).[18]
About the type of therapy, more than half (59.5%) of studied patients were treated surgically. This result was reported in a study done in AL-Najaf General Hospital: 74.3% patients underwent surgical operation, and the others were treated conservatively (25.68%),[19] but the rate was half in another study (30%–40%).[28]
The outcome of our patients was 53.7% discharged healthy, 31.5% discharged unhealthy for further management, and 14.8% of them died. Hence, the mortality rate in this study was lower than other study, 20% was found in Basrah General Hospital,[25] but higher than AL-Najaf study mortality rate was 5.5%,[19] and 6.7% reported at the Hospital of St. Bernard Parish.[29]
| Conclusion | | |
Pain is the most common complaint among the studied patients, and right iliac fossa was the common site of pain and most patients attended to the hospital late (after 24 h from starting the symptoms). The most common associated illness of the studied patients was cardiovascular diseases (hypertension, angina, and heart failure). Perforated viscus and cholecystitis appears to be the main causes of acute abdomen among elderly people in this study while the mortality rate is still considerably high that necessitates careful evaluation of elderly patients presenting with abdominal pain to decrease the rate of misdiagnoses and mortality
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | |
| 2. | Ragsdale L, Southerland L. Acute abdominal pain in the older adult. Emerg Med Clin North Am 2011;29:429-48, x.  |
| 3. | Ozkan E, Fersahoğlu MM, Dulundu E, Ozel Y, Yıldız MK, Topaloğlu U. Factors affecting mortality and morbidity in emergency abdominal surgery in geriatric patients. Turk J Trauma Emerg Surg 2010;16:439-44. |
| 4. | Al-Obaidi MA, Noori SM. Acute abdomen in patients above sixty. Iraqi Med J 2004;34:12-20. |
| 5. | Meldon S, Ma OJ, Woolard R. Geriatric Emergency Medicine, American College of Emergency Physicians. 2 nd ed. New York: :McGraw-Hill; 2004. p. 55-69. |
| 6. | Beers MH, Berkow R. Surgery & rehabilitation. In: Beers MH, Berkow R, editors. The Merck Manual of Geriatric. 3 rd ed., Sec. 3. West Point, PA: Merck & Co. Inc.; 2001. p. 240-2. |
| 7. | Martinez JP, Mattu A. Abdominal pain in the elderly. Emerg Med Clin North Am 2006;24:371-88, vii. |
| 8. | Sherman ED, Robillard E. Sensitivity to pain in the aged. Can Med Assoc J 1960;83:944-7. |
| 9. | Chang CC, Wang SS. Acute abdominal pain in the elderly. Int J Gerontol 2007;1:77-82. |
| 10. | Zachary C. A History of the Acute Abdomen. London: Oxford University Press; 1965. p. 123-355. |
| 11. | Tazkarji MB. Abdominal pain among older adults. Geriatr Aging 2008;11:410-5. |
| 12. | Lyon C, Clark DC. Diagnosis of acute abdominal pain in older patients. Am Fam Physician 2006;74:1537-44. |
| 13. | Choung RS, Locke GR 3 rd, Schleck CD, Zinsmeister AR, Talley NJ. The effects of ageing on the onset and disappearance of unexplained abdominal pain: A population-based study. Aliment Pharmacol Ther 2014;39:217-25. |
| 14. | Kärkkäinen JM, Lehtimäki TT, Manninen H, Paajanen H. Acute mesenteric ischemia is a more common cause than expected of acute abdomen in the elderly. J Gastrointest Surg 2015;19:1407-14. |
| 15. | Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: A review. Ann Emerg Med 2010;56:261-9. |
| 16. | Hustey FM, Meldon SW, Banet GA, Gerson LW, Blanda M, Lewis LM. The use of abdominal computed tomography in older ED patients with acute abdominal pain. Am J Emerg Med 2005;23:259-65. |
| 17. | Metha SS. Abdominal pain in the elderly. Med Update 2008;18:244-6. |
| 18. | Gürleyik G, Gürleyik E, Unalmişer S. Abdominal surgical emergency in the elderly. Turk J Gastroenterol 2002;13:47-52. |
| 19. | Al-Saiegh AM, AI-Safar RS, Al-Jubori KS. Acute abdomen in elderly patients. Med J Babylon 2006;3:220-9. |
| 20. | Gebre S. Causes and outcome of surgically treated non-traumatic surgical acute abdomen in Suhul General Hospital in Ethiopia, prospective study. Am Sci Res J Eng Technol Sci 2014;16:74-89. |
| 21. | Jeong SK, Lim JY, Hong SY, Choi SM, Choi SP. Chief complaints and related features of elderly patients presenting to one region wide emergency medical center with medical problems. J Korean Geriatr Soc 2013;17:118-25. |
| 22. | Pappas A, Toutouni H, Gourgiotis S, Seretis C, Koukoutsis I, Chrysikos I, et al. Comparative approach to non-traumatic acute abdominal pain between elderly and non-elderly in the emergency department: a study in rural Greece. J Clin Med Res 2013;5:300-4. |
| 23. | Sanson TG, O'Keefe KP. Evaluation of abdominal pain in the elderly. Emerg Med Clin North Am 1996;14:615-27. |
| 24. | Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? JAMA 2003;289:80-6. |
| 25. | Al-Hussainy AZ, Al-Hawa MH, Abdulla MA. Acute abdominal surgical emergency in elderly patients. MJBU 2009;27:5-10. |
| 26. | Costamagna D, Pipitonefederico NS, Erra S, Tribocco M, Poncina F, Botto G, et al. Acute abdomen in the elderly. A peripheral general hospital experience. Giugno Luglio 2009;30:315-22. |
| 27. | Zeina AR, Shapira-Rootman M, Mahamid A, Ashkar J, Abu-Mouch S, Nachtigal A. Role of plain abdominal radiographs in the evaluation of patients with non-traumatic abdominal pain. Isr Med Assoc J 2015;17:678-81. |
| 28. | Bryan ED. Abdominal pain in elderly persons. E Med 2005;19:110-6. |
| 29. | Espinoza R, Balbontín P, Feuerhake S, Piñera C. Acute abdomen in the elderly. Rev Med Chil 2004;132:1505-12. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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